Pain Management Still a Constraint to Outpatient Procedures

Surgery is on the move: With enhanced recovery protocols, procedures that once required several days of in-hospital recovery are shifting to the outpatient setting without compromising patient care. However, there are still major barriers to consider.

At the Interdisciplinary Conference on Orthopedic Value-Based Care, Tong Joo (T.J.) Gan, MD, FRCA, MHS, assessed the feasibility of outpatient arthroplasty and selected spine procedures. “Carefully selected patients in combination with enhanced recovery principles and pathways enable total knee replacement and spinal surgery to be done on an outpatient basis,” said Dr. Gan, who is professor and chairman of the Department of Anesthesiology, Stony Brook Medicine, in New York, “but pain management, postoperative nausea and vomiting (PONV) and rehabilitation are major constraints.”

Barriers to Outpatient Procedures

In a narrative review by Henrik Kehlet, MD, the so-called “father of enhanced recovery after surgery” (ERAS), several potential barriers to outpatient total knee arthroplasty were delineated, including the patient’s social network and comorbidity profile, but pain was the major limiting factor (Bone Joint J 2015;97-B[10 Suppl A]:40-44). “Severity of pain was shown to be one of the main causes of increased length of stay,” Dr. Gan said. “Approximately 50% of patients reported moderate to major pain following surgery, and 30% had either severe or extreme pain.”

According to Dr. Gan, however, while the current pain management paradigm—opioid monotherapy—may control pain symptoms, it also can lead to side effects that hamper recovery, namely drowsiness, nausea and vomiting, urinary retention, delirium, constipation and dizziness.

“We have to think about the consequences of the drugs that we use,” said Dr. Gan, who noted that by reducing opioid-related side effects, providers can reduce costs and shorten length of stay. “We’ve got to change our approach to a multimodal strategy that addresses the complex nature of pain transmission.”

For mild to moderate pain, Dr. Gan noted that many professional societies, including the American Society of Anesthesiologists, recommend starting patients on acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 inhibitors (coxibs), gabapentinoids and/or local anesthetics instead of opioids. By reserving opioids for rescue analgesia and incorporating regional blocks, many programs around the country can achieve opioid-sparing or even nonopioid surgery, he reported.

“Regional blocks are one of the most effective opioid-sparing techniques, and the adductor canal block has become very popular for lower limb procedures such as arthroscopic knee surgery,” Dr. Gan said. Whether the adductor canal block is more effective than the traditional femoral nerve block remains to be seen, he added, but recent analysis suggests a potential for less motor blockade and thus increased postoperative mobilization (Ambulatory Anesthesia 2015;2016:1-12).

According to Dr. Gan, the administration of small doses of ketamine can be an effective strategy. Results of a study of opioid-dependent patients undergoing major lumbar spine surgery showed that intraoperative ketamine reduced opioid consumption and pain intensity throughout the postoperative period, without increasing side effects and up to six months after surgery (Anesthesiology2010;113:639-646).

PONV poses an additional challenge, with functional interference due to emetic symptoms approaching 50% in one prospective, multicenter, observational study (Anesth Analg 2008;107[2]:452-458). Nevertheless, Dr. Gan noted, these risks can be predicted and effectively prevented. Female sex, history of PONV or motion sickness, and nonsmoker status were identified as risk factors in the study, but the administration of combination antiemetics produced significantly better outcomes.

Low-dose gabapentin (300-600 mg) also can be used in the perioperative period to reduce nausea and vomiting by decreasing opioid consumption, according to Dr. Gan.

In addition, new analgesics and novel delivery systems in the pipeline could provide exciting options for physicians in the future. Cannabinoids, antibodies targeting nerve growth factor, and selective G protein–couple receptors are all promising areas of investigation, Dr. Gan pointed out. Oliceridine (Trevana), a mu-opioid receptor modulator that shows fewer opioid-related side effects, potentially could reduce incidents of respiratory depression and gastrointestinal dysfunction.

Opioid Risk Screening

While acknowledging the dangers of opioid abuse, Thomas Vetter, MD, director of perioperative care and professor of surgery and perioperative care at the University of Texas at Austin, Dell Medical School, advocated the benefits of opioid analgesia in selected patient populations.

“Approximately one in 10 patients will develop issues with opioids postoperatively,” Dr. Vetter said. “These unfortunate patients may have coexisting anxiety and depression that’s been under- or nondiagnosed or a predilection because addiction is a neurobiological disorder; or they may smoke, accelerating their osteoarthritis and spinal disease, making them poor surgical candidates.”

However, by categorically dismissing opioids as “bad,” Dr. Vetter added, patients who would do well on low-dose, short-term opioids may end up receiving inadequate pain management. Instead, he said, providers should focus on opioid risk assessment.

“Opioids are effective analgesia, especially in patients with chronic pain, and there is no ceiling effect,” Dr. Gan replied, “but we currently lack the knowledge and technology to distinguish opioid-sensitive patients from those who may be resistant.

“Nevertheless,” Dr. Gan added, “great work has been done to categorize different subspecies of mu-opioid receptors along with patient response. More advanced genetic testing that enables providers to screen patients for the enzyme responsible for opioid metabolism is on the horizon. Opioids are still necessary, but as part of a multimodal strategy.”

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